Clinical Question

Do interventions that aim to facilitate shared decision making reduce the prescribing of antibiotics for acute respiratory tract infections in primary care?

Evidence-Based Answer

Interventions to facilitate shared decision making reduce the prescribing of antibiotics for acute respiratory tract infections in the short term (within six weeks of the consultation) without increasing return visits or decreasing patient satisfaction (number needed to treat [NNT] = 6).¹ (Strength of Recommendation: A, based on consistent, good-quality, patient-oriented evidence.)

Practice Pointers

Multiple systematic reviews have shown that antibiotics prescribed for acute respiratory tract infections have minimal benefit because these are predominantly viral infections.^2,3 According to the Centers for Disease Control and Prevention, more than one-half of antibiotic prescriptions in outpatient settings are inappropriately written for viral infections, contributing to resistant bacteria causing more than 2 million illnesses in the United States each year.^4,5 Shared decision making is a process by which the physician and patient share information including risks, benefits, the best available evidence, and personal values, ultimately reaching agreement on a plan of action.⁶ This Cochrane review evaluated whether interventions educating physicians on shared decision making for acute respiratory tract infections reduce antibiotic prescribing for these infections in primary care.¹ For the purposes of this review, respiratory tract infections included acute cough, rhinosinusitis, pharyngitis, tonsillitis, laryngitis, otitis media, bronchitis, exacerbated chronic obstructive pulmonary disease, and influenza.

This Cochrane review included approximately 492,000 patients in nine randomized trials and one follow-up of an original trial.¹ Studies varied by the specific type of intervention and number of study arms. All interventions involved educating physicians about shared decision making and how to discuss differences between bacterial and viral infections. All included studies explicitly addressed shared decision making and had interventions that involved training or tools such as decision aids to assist physicians.

Pooled results from eight studies showed that interventions to facilitate shared decision making significantly decreased antibiotic prescriptions in the short term (less than six weeks) with an NNT of 6 (95% confidence interval, 4.8 to 6.7). Thus, for every six encounters for an acute respiratory tract infection with a physician educated on shared decision making, one fewer patient received a prescription for antibiotics. There was no significant increase in reconsultations for the same illness, hospital admissions, incidence of pneumonia, or mortality from respiratory illness, and no significant decrease in patient satisfaction. However, pooled results from three long-term studies showed that interventions did not lead to a sustained decrease in antibiotic prescriptions after 12 months.

Studies did not report on the incidence of infection caused by antibiotic-resistant organisms or the incidence of acute otitis media complications. One limitation of this study is that the primary outcome is antibiotic prescribing. Because some clinicians may choose to write “wait-and-see” antibiotic prescriptions, data on prescriptions filled or actually taken would be more accurate. Additionally, all trials were conducted in Europe and Canada.

The Institute for Clinical Systems Improvement recommends using patient education measures as the primary treatment for acute respiratory tract infections and reserving antibiotics for bacterial infections.⁷ A recent randomized controlled trial implemented clinician-focused interventions to require peer-justification and peer-comparison of antibiotic prescriptions; it showed a significantly lower rate of inappropriate antibiotic prescribing in the intervention group.⁸ Additionally, the American Academy of Family Physicians' Choosing Wisely list recommends against prescribing antibiotics for otitis media in children two to 12 years of age when observation is a reasonable option and against prescribing antibiotics for acute sinusitis.⁹ Health system leaders should consider interventions to facilitate shared decision making as one effective option to assist primary care physicians in reducing inappropriate antibiotic use for acute respiratory tract infections.

The practice recommendations in this activity are available at http://www.cochrane.org.